2. Approach in infertile couple
Firouzeh Akbari Asbagh
Prof. of Gynaecology
Tehran University of Medical Sciences
oct 2014

3. Evaluation sooner in women with irregular
Introduction
An infertility evaluation is usually initiated after one year In women under age 35 years
Women age 35 years and older after six months
Evaluation sooner in women with irregular
menstrual cycles or known risk factors for infertility such as endometriosis, history of PID, reproductive tract malformations

4. Initial approach
Both partners of an infertile couple should be evaluated for factors that could be impairing fertility
Counsel the couple about the possible etiology and offer a treatment plan
The clinician should not ignore the couples emotional state witch may include depression, anger, anxiety, andMaterial discord information should be supportive and informative

5. History
The most important points are:
Duration of infertility and results of previous evaluation and therapy
Menstrual history (cycle length and characteristic )
Helps in determining ovulatory status
Medical, surgical, and gynecology history
PID thyroid disease, galactorrhea, hirsutism, pelvic, dysmenorrhea, or dyspareunia
Young women who have undergone unilateral oophorectomy generally do not reduced fertility but in older women as they may develop diminished ovarian reserve sooner than women with two ovaries
Obstetrical history outcome in a future pregnancy

6. Sexual history including sexual dysfunction and frequency of coitus
Family history including family, birth defects, genetic mutations, or mental retardation
Women with fragile X permutation may develop POF
Personal and lifestyle history including age, occupation, exercise, stress, dieting/changes in weight, smoking, and alcohol use, all of which can affect fertility

7. Physical examination
Physical examination should assess for signs of potential causes of infertility
BMI ,secondary sexual characteristics
Hypogonadotropic hypoganadism , turner syndrome
Abnormalities of the thyroid gland, galactorrhea, androgen excess ( hirsutism …), PCO
Endometriosis (tenderness or masses in the adenxae or posterior cul-de-sac (pouch of Douglas)
Palpable tender nodules
Vaginal / cervical structural abnormalities
Uterine enlargement, irregularity, or lack of mobility are sings of a uterine anomaly, leiomyoma, endometriosis, or pelvic adhesive disease

8. Assessment of ovulatory function Laboratory assessment
Mid-luteal phase serum progesterone level >3 ng/ml
Urinary ovulation prediction kit ( detect LH surg)
5 to 10 % false positive and negative
Daily ultrasound to follow the development of the follicle
Endometrial biopsy it is not good test (too expensive or invasive uncomfortable)
ASRM affirmed the lack of benefit of the endometrial biopsy in the evaluation of the infertile female and dose not recommend

9. Assessment of ovarian reserve
Ovarian reserve can refer to diminished oocyte quality, oocyte quantity or reproductive potential
Over 35 years of age and younger women with risk factors POF
Day 3 FSH (advantage: cost , simple )
less than 10 mlU /ml adequate ovarian reserve
Levels 10 to 15 mlU /ml borderline
FSH more than 20 mlU /ml insufficient
day 3 estradiol levels <80 pg/ml adequate ovarian reserve
day 3 estradiol levels >80 pg/ml high cancellation rates
Low pregnancy rate
day 3 estradiol levels >100 pg/ml % pregnancy rate
Clomiphene citrate challenge test (CCCT)

10. Antral follicle count (AFC)
TVS
Size (2 to 10 mm)
low AFC ranging from 4 to 10 antral follicles between days two and four of a regular menstrual cycle suggests poor ovarian reserve
AFC is a good predictor of ovarian reserve and response less predictive of oocyte quality the
ability to conceive with IVF and pregnancy outcome

11. Anti- Mullerian hormone (AMH)
AMH level an early, reliable, direct indicator of declining ovarian function
Patients have had significant ovarian injury from radiation or surgery
Patient planning IVF AMH level correlates with the number of oocytes retrieved after stimulation and is the best biomarker for predicting poor and excessive ovarian response
Measured anytime during the menstrual cycle

12. General guidelines
AMH <0.5 ng/ml predicts reduced ovarian reserve with less than three follicles in an IVF cycle
AMH <1.0 ng/ml predicts baseline ovarian reserve with a likelihood of limited eggs at retrieval
AMH >1.0 ng/ml but <3.5 ng/ml suggests a good response to stimulation
AMH >3.5 ng/ml predicts a vigorous response to ovarian stimulation and caution should be exercised in order to avoid OHSS

13. Assessment fallopian tube patency&
Uterine cavity
HSG
first -line test
Water or lipid soluble contrast
Abnormalities such as Submucous fibroids a T- shaped cavity, polips, synechiae, and congenital Mullerian anomalies
HSG is not useful for detecting peritubal adhesions or endometriosis
Abnormalities found on HSG hysteroscopy, or laparoscopy
hysteroscopy definitive method for evaluation abnormalities of the endometrial cavity diagnosis and treatment
Chlamydia antibodies

14. Hysterosalpango- contrast sonography (HyCoSy)
Safe well tolerated, quick and easy method for obtaining information on tubal status the uterine cavity, the ovaries, and the myometrium using conventional ultrasound
HyCoSy is a simple time –efficient and effective method for evaluation of tubal patency, the uterine cavity , and the myometrium

15. Role of laparoscopy The evaluation of infertility is Controversial
Invasive and expensive
Indication
Endometriosis and adhesions/tubal disease…
Laparoscopy and hysteroscopy

16. Test of limited clinical utility
postictal test
Not recommend
Basal body temperature records
Zona- free hamster oocyte penetration test
Mycoplasma cultures
karyotype